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the eighth day

March 25, 2011

'Unproductive burdens' still have a right to live

Here's a perspective on euthanasia that deserves to be circulated as widely as possible. It appears in today's edition of The Australian, and is written by David van Gend

THERE was a moment during the last national debate on euthanasia that deserves to be revisited by a new generation of legislators, a moment that crystallised fears that the so-called right to die would come to be felt by the frailest among us more as a "duty to die".

It was 1995 and our then governor-general, Bill Hayden, was addressing the College of Physicians during debate on the Northern Territory's euthanasia laws. The scene was significant, since the dual concern with euthanasia is the corruption of the relationship between the state and its most vulnerable citizens, and between doctors and their most vulnerable patients.

Our head of state urged doctors to support euthanasia not only as a right, but also as a positive duty towards society. He reflected on past cultures where the elderly would take their lives when their usefulness had passed, and declared of our own culture: "There is a point when the succeeding generations deserve to be disencumbered of some unproductive burdens."

The next day a retired state governor, Mark Oliphant, publicly supported Hayden's astonishing message to "unproductive burdens" that they should do the right thing by society. This is the callousing of social attitudes, the insidious pressure on the frail and demoralised, that we could expect within a culture of mercy-killing.

A year earlier in Britain, a House of Lords select committee on medical ethics completed the most thorough enquiry into euthanasia ever undertaken, and concluded in stark contrast to Hayden: "The message which society sends to vulnerable and disadvantaged people should not, however obliquely, encourage them to seek death, but should assure them of our care and support in life."

This committee began with a majority in favour of euthanasia, but ended by rejecting it as unsafe and corrupting public policy:

"It would be next to impossible to ensure that every act of euthanasia was truly voluntary. We are concerned that vulnerable people - the elderly, lonely, sick or distressed - would feel pressure, whether real or imagined, to seek early death."

Doctors have no illusions about the pressures that can be felt by vulnerable people.

One patient of mine, a woman with disabilities and minimal self-confidence, received a cruel letter from a close relative effectively telling her she should be dead, and demanding certain arrangements in her will. She then developed cancer.

Consider such family dynamics in a setting of legalised euthanasia, and ask what the "right to die" would mean to a cancer patient so isolated and intimidated.

And the public should have no illusions about the corruptibility of doctors if they are given authority to take life.

According to the Dutch government's own data, doctors in The Netherlands put to death several hundred patients a year without any explicit request, even where the patient is competent to give or withhold consent.

The Dutch officially legalised voluntary euthanasia in 2002 and some claimed that bringing euthanasia "out into the open" in this way would reduce such abuses. Not at all. The Netherlands' 2007 report on euthanasia states that the rate of patients killed "without explicit request" since legalisation in 2002 is "not significantly different from those in previous years".

And why would we expect a reduction?

Doctors who treated the law with contempt when euthanasia was illegal would be even more comfortable and relaxed about abusing the practice once it was socially approved.

Professors of psychiatry in Brisbane, Frank Varghese and Brian Kelly, warned of the impossibility of protecting patients from "the doctor's unconscious and indeed sometimes conscious wishes for the patient to die" once doctors run the state machinery of mercy-killing.

Even the assertion by euthanasia advocates that psychiatric assessment will protect patients by detecting any depression that might be marring the patient's judgment is shown to be a sham, on the available evidence from the US State of Oregon and the Northern Territory.

In Oregon, for instance, of the 49 patients who died by physician-assisted suicide in 2007 not a single patient was referred for psychiatric assessment prior to taking their lethal drug. In the NT during the period of legal euthanasia (July 1996 to March 1997) there were four deaths, all presided over by euthanasia advocate Philip Nitschke.

Psychiatrist and palliative care specialist David Kissane reviewed Nitschke's cases and made this assessment of the so-called "safeguard" of compulsory psychiatric assessment:

"Nitschke reported that all patients saw this step as a hurdle to be overcome. Alarmingly, these patients went untreated by a system preoccupied with meeting the requirements of the act's schedules rather than delivering competent medical care to depressed patients."

More than once I have urged Nitschke to study palliative medicine, to broaden his awareness of what can be done for people with advanced disease. When we look after such patients well, thoughts of euthanasia often fade. Then, in the words of one hospice patient who had asked me for euthanasia only the day before, but was now pain-free, "It's a different world, doc."

However, I would not use the argument against euthanasia that "palliative care can ease all suffering". We cannot ease all suffering in dying any more than we can ease all suffering in childbirth, even though we have made enormous progress.

Rejection of euthanasia is not dependent on perfecting palliative care for all patients.

Its rejection is on the grounds of injustice to the weak, as Kevin Andrews made clear on presenting his Euthanasia Laws Bill 1996, which overturned the NT's legislation: "The people who are most at risk are the most vulnerable, and a law which fails to protect vulnerable people will always be a bad law."

We must reject euthanasia both as a corruption of the doctor-patient relationship and as an insidious oppression of society's "unproductive burdens".

And parliament must reject the Greens' trivialisation of such a momentous issue, their proposal that five politicians on Norfolk Island or nine in the ACT assembly should have authority to transform national culture on a matter of life and death.

David van Gend is a Toowoomba GP and a senior lecturer in palliative medicine at the University of Queensland. (This article does not purport to represent the view, if any, of the university.)